Compositions and methods for treating non-alcoholic steatohepatitis

ABSTRACT

Compositions and method are disclosed comprising ethyl icosapentate for use in treatment of non-alcoholic steatohepatitis (NASH).

TECHNICAL FIELD

The present invention relates to compositions and methods comprising ethyl icosapentate for treatment of non-alcoholic steatohepatitis (NASH).

BACKGROUND ART

It is known that heavy alcohol use can lead to liver complications, including alcoholic hepatitis which is often characterized by fatty liver and inflammation. Alcoholic hepatitis can ultimately lead to cirrhosis of the liver (scarring) and hardening of the liver tissue.

Individuals that do not consume excessive amounts of alcohol can also be found to have liver disease complications. Non-alcoholic fatty liver disease (NAFLD) is understood to encompass a variety of liver diseases, including steatosis (simple fatty liver), non-alcoholic steatohepatitis (NASH) and advanced scarring of the liver (cirrhosis). NASH has traditionally been diagnosed by means of a liver biopsy to characterize the liver histology, particularly with respect to the characteristics of inflammation, fibrosis and steatosis (fat accumulation). NASH then generally prefers to clinical findings based upon the liver biopsy of a patient with steatohepatitis, combined with the absence of significant alcohol consumption (Neuschwander-Tetri, B. A. and S. H. Caldwell (2003) Hepatology 37(5): 1202-1209). In NASH, fat accumulation is seen in varying degrees of inflammation (hepatitis) and scarring (fibrosis). Patients having NASH are also often characterized by abnormal levels of liver enzymes, such as aspartate aminotransferase (AST, GOT) and alanine aminotransferase (ALT, GPT). However, a clinical diagnosis of NASH still depends upon a liver biopsy to assess the histologic characteristics of the patient's liver, such that histological examination of liver biopsy tissue is often characterized as the “gold-standard” technique for the assessment of liver fibrosis (Neuschwander-Tetri, ibid).

CITATION LIST Non Patent Literature

Non Patent Literature 1: Hepatology June 2005; 41:1313-1321 “Design and validation of a historical scoring system for nonalcoholic fatty liver disease”

SUMMARY OF INVENTION Technical Problem

The object of the present invention is to provide the compositions and methods comprising ethyl icosapentate for the treatment or alleviation of non-alcoholic steato-hepatitis (NASH), and alleviation of the symptoms associated with NASH.

Solution to Problem

In one embodiment of the invention is that a pharmaceutical agent for treatment or alleviation of symptoms of non-alcoholic steatohepatitis (hereinafter abbreviated as NASH), an effective amount of ethyl icosapentate is administered.after determining in a subject a baseline level indicative of NASH of at least one criteria selected from the group consisting of NAS score, steatosis score, lobular inflammation score, ballooning score and fibrosis stage.

In (1) embodiment of the invention Ethyl icosapentate for use in the treatment or alleviation of symptoms of NASH in a subject in need thereof, wherein:

(a) a baseline level in a subject having NASH of at least one criteria selected from the group consisting of NAS score, steatosis score, lobular inflammation score, ballooning score and fibrosis stage is determined; and

(b) an effective amount of ethyl icosapentate (EPA-E) is administered to said subject.

(2) The ethyl icosapentate for use of (1), wherein said subject has a NAS score of 4 or more than 4.

(3) The ethyl icosapentate for use (1) or (2), wherein said subject is characterized by at least one criteria selected from the group consisting of a baseline ALT value of 10 to 300 U/L; a baseline AST value of 10 to 250 U/L; a baseline steatosis grade of 2 to 3; and a baseline lobular inflammation grade of 2 to 3.

(4) The ethyl icosapentate for use of any one of (1) to (3), wherein after said administration of said EPA-E for about one year, said subject exhibits at least one improvement selected from the group consisting of a reduced ALT value as compared to said baseline ALT value; a reduced AST value as compared to said baseline AST value; a reduced steatosis grade as compared to said baseline steatosis grade; and a reduced lobular inflammation grade as compared to said baseline lobular inflammation grade.

(5) The ethyl icosapentate for use of any one of (1) to (4), wherein said ethyl icosapentate is administered to said subject in an amount of between 300 to 4000 mg per day.

(6) The ethyl icosapentate for use of any one of (1) to (5), wherein said subject is further characterized by having at least one condition selected from the group consisting of high TG, low HDL-C, diabetes, impaired glucose tolerance and metabolic syndrome.

(7) The ethyl icosapentate for use of any one of (4) to (6), wherein said reduced ALT value is at least 5% lower than said baseline ALT value and/or said reduced AST value is at least 5% lower than said baseline AST value.

(8) The ethyl icosapentate for use of any one of (1) to (7), further comprising determining in said subject prior to treatment a baseline level in serum of at least one member selected from the group consisting of ALT in a range of 10 to 300 U/L, AST in a range of 10 to 250 U/L, HDL-C in a range of 25 to 55 mg/dl, LDL-C in a range of 100 to 200 mg/dl, triglycerides in a range of 100 to 1000 mg/dl, TC in a range of 170 to 300 mg/dl, High TG and low HDL-C, TG/HDL-C ratio in a range of 3.75 to 10, non-HDL-C in a range of 100 to 250 mg/dl, Free fatty acid in a range of 400 to 1000 micro Eq/L, HOMA-IR in a range of 1.5 to 5, HbA1c in a range of 5.7 to 10%, Fasting plasma glucose in a range of 100 to 200 mg/dl.

(9) The ethyl icosapentate for use of any one of (1) to (8), wherein after administration of ethyl icosapentate for at least 3 months, said subject exhibits the following changes in said at least one marker as compared to the baseline level of at least 1% reduction for ALT, AST, TG, TG/HDL ratio, Free fatty acid, AA, MUFA, Palmitoleic acid, Oleic acid, Oleic acid/Stearic acid ratio, Palmitoleic acid/Palmitic acid ratio, Adrenic acid/AA ratio, Ferritin, Thioredoxin, TNF-alpha, sTNF-R1, sTNF-R2, Hs-CRP, CRGF, sCD40, Leptin, complement factor D, CK18 fragment, serum HMGB1, soluble Fas antigen, Hyaluronic acid, Type IV collagen (7s domain), procollagen III peptide or PAI-1; at least 5% increase for EPA or EPA/AA ratio; at least 1% increase for DPA, AA/Homo-gamma-linolenic acid ratio or Serum adiponectin; no worsening of ALP, bilirubin, GGT, Albumin, HDL-C, LDL-C, TC, non-HDL-C, HOMA-IR, HbAp1c, Glucose, Fasting plasma glucose, postprandial plasma glucose, OGTT, platelet count or BMI.

(10) The ethyl icosapentate for use of any one of (1) to (9), wherein: the NAS score in said subject after administering (i) to a composite score of 3 or less than 3 and no worsening of said fibrosis stage score, or (ii) by 2 or more than 2 across at least two of the NAS components and no worsening of said fibrosis stage score is improved.

In another embodiment of the invention the ethyl icosapentate for use in the treatment or alleviation of symptoms of NASH, wherein an effective amount of ethyl icosapentate is administered to a subject for treating NASH after identifying the subject having NASH; determining the baseline level in the subject of at least one criteria selected from the group consisting of NAS score, steatosis score, lobular inflammation score, ballooning score and fibrosis stage.

In another embodiment of the invention ethyl icosapentate for use in the treatment or alleviation of symptoms of NASH, wherein a subject/patient having NASH is identified after determining the baseline level in the subject of at least one criteria selected from the group consisting of NAS score, steatosis score, lobular inflammation score, ballooning score and fibrosis stage; administering to the subject an effective amount of ethyl icosapentate; and improving the NAS score (i) to a composite score of less than 3 or equal to 3 or (ii) by 2 across at least two of the NAS components, combined with no worsening of the fibrosis stage score.

In another embodiment of the invention the ethyl icosapentate for use in treatment or alleviation of symptoms NASH, wherein the identification is a subject having NASH characterized by baseline levels of ALT of between 5 to 300 U/L and at least one criteria selected from the group consisting of NAS score of 4 or more than 4, a steatosis score of 1 or more than 1, a lobular inflammation score of 1 or more than 1 and either (i) a fibrosis stage of at least 1a or (ii) ballooning; administering to the subject an effective amount of ethyl icosapentate; and improving the NAS score in the subject (i) to a composite score of 3 or less than 3 or (ii) by 2 or more than 2 across at least two of the NAS components, together with no worsening of the fibrosis stage score.

In another embodiment of the invention, the ethyl icosapentate for use in treatment or alleviation of symptoms NASH, wherein;

a subject is identified having NASH characterized by baseline levels of ALT of between 5 to 300 U/L and at least one criteria selected from the group consisting of NAS score of 4 or more than 4, a steatosis score of 1 or more than 1, a lobular inflammation score of 1 or more than 1 and either (i) a fibrosis stage of at least 1a or (ii) ballooning, and at least one or any combination of two or more of the pretreatment baseline of the items mentioned in Tables 1 and 2;

a baseline level in blood or physical condition prior to treatment in the subject is determined;

an effective amount of ethyl icosapentate is administered to the subject; and the NAS score in the subject (i) to a composite score of 3 or less than 3, or (ii)

by 2 or more than 2 across at least two of the NAS components, together with no worsening of the fibrosis stage score, optionally improving at least one selected from the items mentioned in Tables 1 and 2 is improved.

In another embodiment of the invention, the ethyl icosapentate for use in treatment or alleviation of symptoms NASH, wherein the subject is taking at least one drug selected from the group consisting of lipid-lowering drugs, HMG-CoA reductase inhibitors (stains), fibrates, probucol, ezetimibe, ursodiol (UDCA), taurine, betaine, N-acetylcysteine, s-adenosylmethionine (SAM-e), milk thistle, anti-TUMOR NECROSIS FACTOR (TNF) therapies, probiotics, anti-diabetic medications, biguanides (metformin), insulin, sulfonylureas, alpha-glucosidase inhibitors (acarbose), dipeptidyl-peptidase 4 inhibitors (sitagliptin, saxagliptin, alogliptin, vildagliptin, linagliptin, etc.), phenylalanine derivatives (nateglinide, repaglinide), anti-platelet therapy, anti-thrombotic agents, Glucagon-like peptide-1(GLP-1) receptor agonists (liraglutide, exenatide, taspoglutide, etc.), PDE-4 inhibitor, angiotensin II-1 type receptor antagonist (ARB: losartan, etc.), polyenephosphatidylcholine, antioxidant (vitamine E, vitamin C, nicotinic acid tocopherol,etc.), and pentoxifylline.

In another embodiment of the invention, ethyl icosapentate for use in the treatment or alleviation of symptoms of NASH wherein,

a subject is identified having NASH characterized by baseline levels of ALT of between 5 to 300 U/L and at least one criteria selected from the group consisting of NAS score of 4 or more than 4, a steatosis score of 1 or more than 1, a lobular inflammation score of 1 or more than 1 and either (i) a fibrosis stage of at least 1a or (ii) ballooning, and at least one or any combination of two or more of the pretreatment baseline of the items mentioned in Tables 1 and 2;

a baseline level in blood or physical condition prior to treatment in the subject is determined;

an effective amount of ethyl icosapentate administering to the subject in combination with at least one drug selected from the group consisting of lipid-lowering drugs, HMG-CoA reductase inhibitors (stains), fibrates, probucol, ezetimibe, ursodiol (UDCA), taurine, betaine, N-acetylcysteine, s-adenosylmethionine (SAM-e), milk thistle, anti-TNF therapies, probiotics, anti-diabetic medications: biguanides (metformin), insulin, sulfonylureas, alpha-glucosidase inhibitors (acarbose), dipeptidyl-peptidase 4 inhibitors (sitagliptin, saxagliptin, alogliptin, vildagliptin, linagliptin, etc.), phenylalanine derivatives (nateglinide, repaglinide), anti-platelet therapy, anti-thrombotic agents, Glucagon-like peptide-1(GLP-1) receptor agonists (liraglutide, exenatide, taspoglutide, etc.), PDE-4 inhibitor, angiotensin II-1 type receptor antagonist (ARB: losartan, etc.), polyenephosphatidylcholine, antioxidant (vitamine E, vitamin C, nicotinic acid tocopherol,etc.), and pentoxifylline; and

the NAS score in the subject is improved (i) to a composite score of 3 or less than 3, or (ii) by 2 or more than 2 across at least two of the NAS components, together with no worsening of the fibrosis stage score, optionally improving at least one of items mentioned in Tables 1 and 2.

In a further embodiment of the invention, ethyl icosapentate for use in the treatment or alleviation of symptoms of NASH wherein a subject an effective amount of ethyl icosapentate is administered, the subject has NASH characterized by baseline levels of ALT of between 5 to 300 U/L and at least one criteria selected from the group consisting of a NAS score of 4 or more than 4, a steatosis score of 1 or more than 1, lobular inflammation score of 1 or more than 1 and either (i) a fibrosis stage of at least 1a or (ii) ballooning; and the NAS score in the subject (i) to a composite score of 3 or less than 3, or (ii) by 2 or more than 2 across at least two of the NAS components, together with no worsening of the fibrosis stage score is improved.

In another embodiment of the invention, ethyl icosapentate for use in reducing steatosis, liver lobular inflammation, ballooning and/or liver fibrosis in a subject in need thereof, wherein, an effective amount of ethyl icosapentate (EPA-E) is administered to a subject; at least one condition selected from the group consisting of the steatosis, lobular inflammation, ballooning and liver fibrosis condition of said subject is improved, and no worsening of said fibrosis stage score; and said subject exhibits the following changes in said at least one marker as compared to a baseline pretreatment level of at least 1% reduction for ALT, AST, Triglycerides (TG), TG/HDL-C ratio, Free fatty acid, Arachidonic acid (AA), monounsaturated fatty acid (MUFA), Palmitoleic acid, Oleic acid, Oleic Acid/Stearic acid ratio, Palmitoleic acid/Palmitic acid ratio, Stearic acid/Palmitic acid ratio, gamma-linolenic acid/Linolenic acid ratio, Adrenic acid/AA ratio, Ferritin, Thioredoxin, Tumor necrosis factor-alpha (TNF-alpha), sTNF-R1(Tumor necrosis factor receptor I, soluble), sTNF-R2(Tumor necrosis factor receptor II, soluble), Hs-CRP, CTGF, sCD40, Leptin, complement factor D, CK18 fragment, serum HMGB1, soluble Fas antigen, Hyaluronic acid, Type IV collagen (7s domain), procollagen III peptide or PAI-1; at least 5% increase for EPA or EPA/AA ratio; at least 1% increase for DPA, AA/Homo-gamma-linolenic acid ratio or Serum adiponectin; no worsening of ALP, bilirubin, GGT, Albumin, HDL-C, LDL-C, Total Cholesterol (TC), non-HDL-C, HOMA-IR, HbA1c, Fasting plasma glucose, postprandial plasma glucose, OGTT, platelet count or BMI.

In another embodiment of the invention, the ethyl icosapentate for use in reducing steatosis, liver lobular inflammation, ballooning and/or liver fibrosis in a subject in need thereof, wherein;

a baseline level in blood or physical condition prior to treatment in the subject having at least one item or any combination of two or more items selected from the pretreatment baseline of the items mentioned in Tables 1 and 2 is determined;

an effective amount of ethyl icosapentate (EPA-E) is administered to the subject;

at least one condition selected from the group consisting of the steatosis, lobular inflammation, ballooning and liver fibrosis condition of said subject without worsening said fibrosis stage score is improved; and

said subject exhibits the described changes in at least one of items mentioned in Tables 1 and 2 as compared to a baseline pre-treatment level of the item.

In another embodiment of the invention, the ethyl icosapentate for use in treatment or alleviation of symptoms NASH, wherein the subject is taking at least one drug selected from the group consisting of lipid-lowering drugs, HMG-CoA reductase inhibitors (stains), fibrates, probucol, ezetimibe, ursodiol (UDCA), taurine, betaine, N-acetylcysteine, s-adenosylmethionine (SAM-e), milk thistle, anti-TNF therapies, probiotics, anti-diabetic medications: biguanides (metformin), insulin, sulfonylureas, alpha-glucosidase inhibitors (acarbose), dipeptidyl-peptidase 4 inhibitors (sitagliptin, saxagliptin, alogliptin, vildagliptin, linagliptin, etc.), phenylalanine derivatives (nateglinide, repaglinide), anti-platelet therapy, anti-thrombotic agents, Glucagon-like peptide-1(GLP-1) receptor agonists (liraglutide, exenatide, taspoglutide, etc.), PDE-4 inhibitor, angiotensin II-1 type receptor antagonist (ARB: losartan, etc.), polyenephosphatidylcholine, antioxidant (vitamine E, vitamin C, nicotinic acid tocopherol,etc.), and pentoxifylline.

In another embodiment of the invention, ethyl icosapentate for use in the treatment or alleviation of symptoms of NASH wherein an effective amount of ethyl icosapentate is administered to a subject, wherein the subject is possible or definite NASH, and a baseline level in blood or physical condition prior to treatment in the subject of at least one member selected from the group consisting of ALT, AST, AST/ALT ratio, ALP, bilirubin, GGT, Albumin, HDL-C, LDL-C, TG, TC, TG/HDL-C ratio, non-HDL-C, Free fatty acid, AA, EPA, DPA, DHA, EPA/AA ratio, DPA/AA ratio, DHA/AA ratio, DHA/DPA ratio, MUFA, Palmitoleic acid, Oleic acid, Oleic acid/Stearic acid ratio, Palmitoleic acid/Palmitic acid ratio, Stearic acid/Palmitic acid ratio, gamma-linolenic acid/Linolenic acid ratio, AA/Homo-gamma-linolenic acid ratio, Adrenic acid/AA ratio, Ferritin, Thioredoxin, TNF-alpha, sTNF-R1, sTNF-R2, Hs-CRP, CTGF, sCD40, HOMA-IR, HbA1c, Glucose, Fasting plasma glucose, postprandial plasma glucose, OGTT, Leptin, Serum adiponectin, complement factor D, CK18 fragment, serum HMGB1, soluble Fas antigen, Hyaluronic acid, Type IV collagen (7s domain), pro-collagen III peptide, PAI-1, platelet count or BMI is determined.

In another embodiment of the invention, the ethyl icosapentate for use in the treatment or alleviation of symptoms of NASH, wherein the subject is possible or definite NASH and an effective amount of ethyl icosapentate is administered to a subject, wherein a baseline level in blood or physical condition prior to treatment in the subject of at least one item or any combination of two or more items selected from the items mentioned in Tables 1 and 2 is determined.

In another embodiment of the invention, the ethyl icosapentate for use in treatment or alleviation of symptoms NASH, wherein the subject is possible or definite NASH and the subject is taking at least one drug selected from the group consisting of lipid-lowering drugs, HMG-CoA reductase inhibitors (stains), fibrates, probucol, ezetimibe, ursodiol (UDCA), taurine, betaine, N-acetylcysteine, s-adenosylmethionine (SAM-e), milk thistle, anti-TNF therapies, probiotics, anti-diabetic medications: biguanides (metformin), insulin, sulfonylureas, alpha-glucosidase inhibitors (acarbose), dipeptidyl-peptidase 4 inhibitors (sitagliptin, saxagliptin, alogliptin, vildagliptin, linagliptin, etc.), phenylalanine derivatives (nateglinide, repaglinide), anti-platelet therapy, anti-thrombotic agents, Glucagon-like peptide-1(GLP-1) receptor agonists (liraglutide, exenatide, taspoglutide, etc.), PDE-4 inhibitor, angiotensin II-1 type receptor antagonist (ARB: losartan, etc.), polyenephosphatidylcholine, antioxidant (vitamine E, vitamin C, nicotinic acid tocopherol,etc.), and pentoxifylline.

In another embodiment of the invention, the ethyl icosapentate for use in the treatment or alleviation of symptoms of NASH wherein an effective amount of ethyl icosapentate is administered to a subject, wherein the subject is possible or definite NASH, and exhibits the following changes in said at least one marker as compared to a baseline pre-treatment level of at least 1% reduction for ALT, AST, TG, TG/HDL-C ratio, Free Fatty acid, AA, MUFA, Palmitoleic acid, Oleic acid, Oleic acid/Stearic acid ratio, Palmitoleic acid/Palmitic acid ratio, Stearic acid/Palmitic acid ratio, gamma-linolenic acid/Linolenic acid ratio, Adrenic acid/AA ratio, Ferritin, Thioredoxin, TNF-alpha, sTNF-R1, sTNF-R2, Hs-CRP, CTGF, sCD40, Leptin, complement factor D, CK18 fragment, serum HMGB 1, soluble Fas antigen, Hyaluronic acid, Type IV collagen (7s domain), procollagen III peptide or PAI-1; at least 5% increase for EPA or EPA/AA ratio; at least 1% increase for DPA, AA/Homo-gamma-linolenic acid ratio or Serum adiponectin; no worsening of ALP, bilirubin, GGT, Albumin, HDL-C, LDL-C, TC, non-HDL-C, HOMA-IR, HbA1c, Glucose, Fasting plasma glucose, postprandial plasma glucose, OGTT, platelet count or BMI.

In another embodiment of the invention, the ethyl icosapentate for use in the treatment or alleviation of symptoms of NASH wherein an effective amount of ethyl icosapentate is administered to a subject being possible or definite NASH, and exhibits the described changes of after dosing value in said at least one item selected from the items mentioned in Tables 1 and 2 as compared to a baseline pre-treatment level thereof.

In another embodiment of the invention, the ethyl icosapentate for use in treatment or alleviation of symptoms NASH, wherein the subject is possible or definite NASH and the subject is taking at least one drug selected from the group consisting of lipid-lowering drugs, HMG-CoA reductase inhibitors (stains), fibrates, probucol, ezetimibe, ursodiol (UDCA), taurine, betaine, N-acetylcysteine, s-adenosylmethionine (SAM-e), milk thistle, anti-TNF therapies, probiotics, anti-diabetic medications: biguanides (metformin), insulin, sulfonylureas, alpha-glucosidase inhibitors (acarbose), dipeptidyl-peptidase 4 inhibitors (sitagliptin, saxagliptin, alogliptin, vildagliptin, linagliptin, etc.), phenylalanine derivatives (nateglinide, repaglinide), anti-platelet therapy, anti-thrombotic agents, Glucagon-like peptide-1(GLP-1) receptor agonists (liraglutide, exenatide, taspoglutide, etc.), PDE-4 inhibitor, angiotensin II-1 type receptor antagonist (ARB: losartan, etc.), polyenephosphatidylcholine, antioxidant (vitamine E, vitamin C, nicotinic acid tocopherol,etc.), and pentoxifylline.

In another embodiment of the invention, the ethyl icosapentate for use in the treatment or alleviation of symptoms of NASH wherein an effective amount of ethyl icosapentate is administered to a subject, wherein the subject is taking at least one drug selected from the group consisting of lipid-lowering drugs, HMG-CoA reductase inhibitors (stains), fibrates, probucol, ezetimibe, ursodiol (UDCA), taurine, betaine, N-acetylcysteine, s-adenosylmethionine (SAM-e), milk thistle, anti-TNF therapies, probiotics, anti-diabetic medications: biguanides (metformin), insulin, sulfonylureas, alpha-glucosidase inhibitors (acarbose), dipeptidyl-peptidase 4 inhibitors (sitagliptin, saxagliptin, alogliptin, vildagliptin, linagliptin, etc.), phenylalanine derivatives (nateglinide, repaglinide), anti-platelet therapy, anti-thrombotic agents, Glucagon-like peptide-1(GLP-1) receptor agonists (liraglutide, exenatide, taspoglutide, etc.), PDE-4 inhibitor, angiotensin II-1 type receptor antagonist (ARB: losartan, etc.), polyenephosphatidylcholine, antioxidant (vitamine E, vitamin C, nicotinic acid tocopherol, etc.), and pentoxifylline.

In another embodiment of the invention, the ethyl icosapentate for use in the treatment or alleviation of symptoms of NASH wherein an effective amount of ethyl icosapentate is administered to a subject, wherein the subject is taking at least one lipid-lowering drug.

In another embodiment of the invention, the ethyl icosapentate for use in the treatment or alleviation of symptoms of NASH wherein an effective amount of ethyl icosapentate is administered to a subject, wherein the subject is taking an HMG-CoA reductase inhibitor (statins; pravastatin sodium, simvastatin, pitavastatin calcium, atorvastatin calcium hydrate, rosuvastatin calcium, etc.).

In another embodiment of the invention, the ethyl icosapentate for use in the treatment or alleviation of symptoms of NASH wherein an effective amount of ethyl icosapentate is administered to a subject, wherein the subject is taking a Glucagon-like peptide-1 (GLP-1) receptor agonist (liraglutide, exenatide, taspoglutide, etc.).

In another embodiment of the invention, the ethyl icosapentate for use in the treatment or alleviation of symptoms of NASH wherein an effective amount of ethyl icosapentate is administered to a subject in combination with at least one drug selected from the group consisting of lipid-lowering drugs, HMG-CoA reductase inhibitors (stains), fibrates, probucol, ezetimibe, ursodiol (UDCA), taurine, betaine, N-acetylcysteine, s-adenosylmethionine (SAM-e), milk thistle, anti-TNF therapies, probiotics, anti-diabetic medications: biguanides (metformin), insulin, sulfonylureas, alpha-glucosidase inhibitors (acarbose), dipeptidyl-peptidase 4 inhibitors (sitagliptin, saxagliptin, alogliptin, vildagliptin, linagliptin, etc.), phenylalanine derivatives (nateglinide, repaglinide), anti-platelet therapy, anti-thrombotic agents, Glucagon-like peptide-1(GLP-1) receptor agonists (liraglutide, exenatide, taspoglutide, etc.), PDE-4 inhibitor, angiotensin II-1 type receptor antagonist (ARB: losartan, etc.), polyenephosphatidylcholine, antioxidant (vitamine E, vitamin C, nicotinic acid tocopherol, etc.), and pentoxifylline.

In another embodiment of the invention, the ethyl icosapentate for use in the treatment or alleviation of symptoms of NASH wherein an effective amount of ethyl icosapentate is administered to a subject, wherein the subject is taking an anti-diabetic drug.

In another embodiment of the invention, the ethyl icosapentate for use in the treatment or alleviation of symptoms of NASH wherein an effective amount of ethyl icosapentate is administered to a subject, wherein the subject is not taking any anti-diabetic drugs.

In another embodiment of the invention, the ethyl icosapentate for use in the treatment or alleviation of symptoms of NASH wherein an effective amount of ethyl icosapentate is administered to a subject, wherein the subject is not diabetic.

In another embodiment of the invention, the ethyl icosapentate for use in the treatment or alleviation of symptoms of NASH wherein an effective amount of ethyl icosapentate is administered to a subject, wherein the subject has diabetes.

In another embodiment of the invention, the ethyl icosapentate for use in the treatment or alleviation of symptoms of NASH wherein an effective amount of ethyl icosapentate is administered to a subject, wherein the subject has impaired glucose tolerance.

In another embodiment of the invention, the ethyl icosapentate for use in the treatment or alleviation of symptoms of NASH wherein an effective amount of ethyl icosapentate is administered to a subject, wherein the subject has metabolic syndrome.

In another embodiment of the invention, the ethyl icosapentate for use in reducing at least one marker as compared to a baseline pre-treatment level of Hs-CRP, CTGF, sCD40, Leptin, complement factor D, serum HMGB1, soluble Fas antigen or pro-collagen III peptide in a subject, comprising administering to a subject an effective amount of ethyl icosapentate (EPA-E), wherein the subject has NASH.

In another embodiment of the invention, the ethyl icosapentate for use in determining efficacy of NASH treatment by (i) administering to a subject an effective amount of EPA-E, (ii) measuring at least one marker of the items mentioned in Tables 1 and 2 during the treatment, (iii) comparing the measured levels of markers to established levels in advance, and optionally (iv) determining whether the treatment is efficacious.

DETAILED DESCRIPTION OF THE INVENTION

The compositions and methods of the present invention are useful for the treatment of NASH by administration of an effective amount of ethyl icosapentate.

Icosapentaenoic acid (EPA) is a known omega-3 polyunsaturated, long-chain fatty acid. Omega-3 fatty acids are known as components of oils, such as fish oil, and a variety of commercial products are promoted as containing omega-3 fatty acids, or their esters, derivatives, conjugates and the like. Icosapentaenoic acid (EPA) is also per se known in its ethyl ester form, ethyl icosapentate (EPA-E). According to the present invention, EPA-E can be administered in a composition. EPA-E content in the total fatty acid of the compositions of the present invention are not particularly limited as long as the composition contains EPA-E as its effective component and intended effects of the present invention are attained, high purity EPA-E is preferably used; for example, the composition having a proportion of the EPA-E of preferably 40% by weight or more, more preferably 90% by weight or more, and still more preferably 96.5% by weight or more in total of the fatty acids and their derivatives. EPA-E can be administered to patients in a highly purified form, including the product known as Epadel (Trade mark) (Mochida Pharmaceutical Co., Ltd., Tokyo Japan). The compositions of EPA-E are administered according to the invention to a subject or patient to provide the patient with a dosage of about 0.3-10 g per day of EPA-E, alternatively 0.6-6 g per day, alternatively 0.9-3.6 g per day or specifically about 300 -4000 mg per day or preferably 900-3600 mg per day or more preferably about 1800-2700 mg per day of EPA-E. The compositions of EPA-E are administered according to the invention to a subject or patient preferably one two, or three times per day.

Since EPAs are highly unsaturated, the preparation as described above preferably contains an antioxidant at an amount effective for suppressing oxidation of the EPAs. Exemplary antioxidants include butylated hydroxytoluene (BHT), butylated hydroxyanisole (BHA), propyl gallate, gallic acid, pharmaceutically acceptable quinone, and alpha-tocopherol.

The composition to be administered can contain other fatty acids, especially any omega-3 unsaturated fatty acid, especially DHA-E. The ratio of EPA-E/DHA-E in the composition, the content of EPA-E and DHA-E in the total fatty acids and administration amount of EPA-E and DHA-E are not limited but the ratio is preferably 0.8 or more, more preferably 1.0 or more, still more preferably 1.2 or more. The composition is preferably highly purified; for example, the proportion of EPA-E+DHA-E in the fatty acids and their derivatives is preferably 40% by weight or more, more preferably 80% by weight or more, and still more preferably 90% or more. The daily amount in terms of EPA-E+DHA-E is typically 0.3 to 10.0 g/day, preferably 0.5 to 6.0 g/day, and still more preferably 1.0 to 4.0 g/day. The low content of other long chain saturated fatty acids is preferred, and among the long chain unsaturated fatty acids, the content of omega-6 fatty acids, and in particular, the content of arachidonic acid is preferably as low as less than 2% by weight, and more preferably less than 1% by weight. For example, soft capsule (Lovaza) (Trade mark) or Omacor (Trade mark) containing about 46% by weight of EPA-E and about 38% by weight of DHA-E is commercially available in the U.S., EP and other countries as a therapeutic agent for hyerptriglyceridemia.

Patients treated for NASH can be administered EPA-E according to the invention for 3, 6 or 9 months, or for 1 year or more and can be administered EPA-E in one, two or three dosage per day, or other multiple doses per day including 1 to about 10, 1 to 8, 1 to 6, 1 to 4 or 1 to 2 dosage units per day as appropriate for patient therapy. The term “dose unit” and “dosage unit” herein refer to a portion of a pharmaceutical composition that contains an amount of EPA-E for a single administration to a subject.

While meal affects absorption of the EPA-E, and the administration of the EPA-E is preferably conducted during the meal or after the meal, and more preferably immediately after the meal (within 30 minutes after the meal).The self-emulsifying composition has excellent absorption under fasting, and therefore, it exhibits the intended effects even when administered at a timing other than during, after, or immediately after the meal.

Compositions comprising EPA-E useful for the invention include commercially available compositions of EPA-E, such as Epadel (Trade mark) noted above. Compositions comprising EPA-E may be administered in tablet, capsule, microcapsule, jelly, enteric preparation, extended release preparation, powder or any other solid oral dosage form, as a liquid, emulsion, self-emulsifying composition, as a soft gel capsule or other capsule form, or other appropriate and convenient dosage forms for administration to a patient in need thereof. Compositions can also include pharmaceutically acceptable excipients known to those of ordinary skill in the art including surfactants, oils, co-solvents or combinations of such excipients, together with stabilizers, emulsifiers, preservatives, solubilizers and/or other non-active pharmaceutical ingredients known to those of skill in the art relative to the preparation of pharmaceutical compositions.

1. Evaluation Criteria for Patients

As noted above, the “gold-standard” for a complete diagnosis of NASH involves a liver biopsy. Patients or subjects treated for NASH according to the present invention can also be evaluated for the following criteria, including evaluation prior to initiation of treatment in order to provide a baseline level or score for the criteria as well as evaluation after the dosing regimen to evaluate any improvement in the criteria.

a. NAS Score:

A non-alcoholic fatty liver disease activity score (NAS) is defined as the unweighted sum of the values for steatosis (ranging from 0-3), lobular inflammation (ranging from 0-3) and ballooning (ranging from 0-2), thereby providing a range of NAS score of from 0 to 8. (See Kleinen et al., Design and Validation of a Histological Scoring System for Nonalcoholic Fatty Liver Disease, Hepatology, Vol. 41, No. 6, 2005, pp. 1313-1321) Patients treated for NASH according to the present invention can show a NAS score prior to treatment of 4 or more than 4, with a minimum score of 1 each for steatosis and lobular inflammation plus either ballooning or at least 1a sinusoidal fibrosis and a finding of possible or definite steatohepatitis. After dosing/treatment, such as for one year, patients can show a composite NAS score of 3 or less than 3, 2 or less than 2, or 1 or less than 1, together with no worsening in fibrosis. Alternatively, patients can show an improvement in NAS by a value of 2 or more than 2 across at least two of the NAS components, together with no worsening in fibrosis. Alternatively, patients can show an improvement in NAS score by 3 or more than 3, 4 or more than 4, 5 or more than 5, 6 or more than 6, 7 or more than 7, or 8 or more than 8.

b. Steatosis:

Steatosis is broadly understood to describe a process involving the abnormal retention of lipids within the liver, which accumulation inhibits the normal liver functions. Liver biopsy enables analysis and scoring of steatosis in a patient, with scores ranging from 0-3. Patients treated for NASH according to the present invention can have a steatosis score of 1, 2 or 3, such as between about 2 and about 3. After treatment, it is desired for patients to exhibit no worsening of steatosis, alternatively a reduction of at least 1 in the steatosis score, or a reduction of 2 or 3 in the steatosis score. Steatosis is traditionally graded with a score of 1 indicating the presence of fat droplets in less than 33% of hepatocytes, a score of 2 indicating fat droplets observed in 33-66% of hepatocytes, and a score of 3 indicating observation of fat droplets in greater than 66% of hepato sites. (See Kleinen et al., Design and Validation of a Histological Scoring System for Nonalcoholic Fatty Liver Disease, Hepatology, Vol. 41, No. 6, 2005, pp. 1313-1321)

c. Lobular Inflammation:

Lobular inflammation is also evaluated upon liver biopsy and scored with values of 0-3. (See Kleinen et al., Design and Validation of a Histological Scoring System for Nonalcoholic Fatty Liver Disease, Hepatology, Vol. 41, No. 6, 2005, pp. 1313-1321 Table 1) Patients to be treated for NASH can have lobular inflammation scores of 1, 2 or 3, alternatively ranging between 1 and 2 or 2 and 3. After treatment, patients can have a reduction in lobular inflammation score of at least 1, alternatively a reduction of 2 or 3 in lobular inflammation score, and at least no worsening of the lobular inflammation score.

d. Ballooning:

Ballooning of hepatocytes is generally scored with values of 0-2, (See Kleinen et al., Design and Validation of a Histological Scoring System for Nonalcoholic Fatty Liver Disease, Hepatology, Vol. 41, No. 6, 2005, pp. 1313-1321 Table 1), and patients treated for NASH according to the present invention can have ballooning scores of 0-2, including specific values of 1 or 2, and alternatively a score ranging from 1 to 2. After treatment, patients can show at least no worsening of the ballooning score, alternatively a reduction of at least one value lower in the ballooning score, and alternatively a reduction of two in the value of the ballooning score.

e. Fibrosis Stage

Fibrosis is also evaluated upon liver biopsy and scored with values of 0-4, the scores being defined as: 0 represents no fibrosis, 1 represents perisinusoidal or periportal fibrosis, 1a represents mild, zone 3, perisinusoidal fibrosis; 1b represents moderate zone 3, perisinusoidal fibrosis; 1c represents portal/periportal fibrosis; 2 represents perisinusoidal and portal/periportal fibrosis; 3 represents bridging fibrosis; and 4 represents cirrhosis. (See Kleinen et al., Design and Validation of a Histological Scoring System for Nonalcoholic Fatty Liver Disease, Hepatology, Vol. 41, No. 6, 2005, pp. 1313-1321) Patients treated according to the present invention can have a fibrosis stage score of 0-3, including 0, 1, 1a, 1b, 1c, 2 or 3, and can have a fibrosis stage score of at least la. After treatment, patients can have a fibrosis stage score that is at least no worse than the baseline score, and alternatively can have a reduction in the fibrosis stage score of at least one level, alternatively at least two or three levels.

2. Additional Criteria/Markers for Evaluation of Patients

As noted above, while liver biopsy is considered the “gold-standard” for clinical assessment of NASH, the condition can also be accompanied or associated with abnormal levels of liver enzymes and other biological blood components. Therefore, patients treated for NASH according to the present invention can also be evaluated for baseline scores of the following criteria before treatment, and evaluated after treatment for possible changes in those criteria. The evaluated criteria can comprise one or more of the following criteria set forth in Tables 1 and 2.

In the present invention, a biological sample of the patient is collected and used to obtain measurement values. Specific examples of the biological sample include blood, plasma, serum, urine, body fluids, and tissues, but are not limited thereto. The biological sample is preferably blood, plasma or serum. The biological sample is collected from a subject by a known method.

In the present invention, a normal value is measured in accordance with a known measuring method if the normal value is known as one of the blood test indices used to detect NASH, or in accordance with a measuring method following a reference document or the like if a common measuring method for the normal value is not established.

For instance, the normal values shown in Tables 1 and 2, except BMI, can be each measured with a biological sample of either blood, plasma or serum. Fatty acids in blood may be used to measure fatty acids. Table 3 shows a list of some reference documents which recite the particulars of the measurement method.

Unless otherwise specified, the fatty acid amount and the fatty acid composition ratio as used in the present invention may be the amount and the composition ratio of fatty acids in any of the plasma, serum and liver. It is also possible indeed to use the fatty acid amount and the fatty acid composition ratio in a specified fraction, such as LDL or VLDL in the blood. It, however, is desirable to use the amount and the composition ratio of fatty acids in the plasma or the serum because of the simplicity of measurement. Each fatty acid to be employed for the calculation of the fatty acid amount and the fatty acid composition ratio is not particularly limited in unit of amount, that is to say, its amount may be expressed in mole, mole percent, a unit of weight, percent by weight, or the like. The sole unit, and the sole method of calculating fatty acid amount and the fatty acid composition ratios should be used if the evaluation is to be made by the comparison of the fatty acid amount and the fatty acid composition ratio over time. It is particularly desirable to calculate the fatty acid amount and the fatty acid composition ratio from fatty acid amounts expressed in mole percent of the total amount of fatty acids. The weight/volume concentration (e.g., micro g/ml), the mole/volume concentration (e.g., mol/L) or the like may also be used for the calculation.

In this description, the term “plasma fatty acid” refers to a plasma total fatty acid unless otherwise specified. It is also possible to use a plasma free fatty acid for the inventive index for the evaluation of the subject's condition or therapeutic effects. The term “liver fatty acid” refers to a liver total fatty acid unless otherwise specified. A liver free fatty acid may optionally be used.

The fatty acid composition may be determined by any method practicable by a person of ordinary skill in the art of the present invention, while it is particularly preferable to determine the composition according to a usual manner.

TABLE 1 Pre-treatment baseline After dosing (effect) values Item Observable Observable (Typical Normal Typical Ranges or Typical Ranges or Values, Units) Range(s) Values Range(s) Values ALT (alanine 10-300 Lower limit at least 1% 1 to about 95% aminotransferase, range values of lower reduction GPT) 10, 50, 100, 150, (6-41 U/L) or 200, upper limit range values of 100, 150, 200, 250, or 300, ranges of 10-300, 10- 200, 10-150, 10- 100, 100-200, 2000-3000 AST (asparate 10-250 Lower limit at least 1% 1 to about 95% aminotransferase, range values of lower reduction GOT) 10, 50, 100, 150, (9-34 U/L) or 200, upper limit range values of 100, 150, 200, 250, or 300, ranges of 10-300, 10- 200, 10-150, 10- 100, 100-200, 200-300 AST/ALT ratio upper limit range values of 0.5, 0.7, 0.8, 1, 1.2, 2; ranges of 0.5-2, 0.5-1, 1-2 alkaline 80-300 ranges of 50-600 no worsening no worsening, 1 phospatase to about 90% (ALP) reduction, (80-260 IU/L) 300 IU/L or less, 250 IU/L or less Total bilirubin High no worsening no worsening, 1 (0.2-1.2 mg/dL) compared to to about 90% average level reduction, of normal subject Gamma- High no worsening no worsening, 1 Glutamyl compared to to about 90% Transferase average level reduction, (GGT or γGTP) of normal 100 U/L or less, (males: 5-60 U/L) subject 70 U/L or less Albumin Low no worsening no worsening, 1 (3.8-5.2 g/dl) compared to to about 90% average level increase, ranges of normal of 3-6 g/dl, 3.5- subjects 5.5 g/dl HDL-C (high less than 55 less than no worsening, at no change, 1- density 60 mg/dl, 55, 50, least 1% 90% increase, lipoprotein 45, 40, 35, 30, increase 40 mg/dl or cholesterol) 25, or 25 mg/dl; more (35-60- mg/dl) ranges of 25-55, 30-40 mg/dl, 40- 50 mg/dl, 50- 60 mg/dl, at least 60 LDL-C (low 100-200 at least 70 no worsening no change, 1- density mg/dl, 100, 90% reduction lipoprotein 120, 130 140 less than cholesterol) 150, 170, 190, 160 mg/dl, 140, (50-130 mg/dl) or 200 or a 130, 120, 100, range of 70-300, 70 mg/dl 70-250, 70-200, 100-250, 100- 200, 130-200, 140-180, 100- 130, 130-160, 160-190 Triglycerides 100-1000 at least 80 at least 1% 1 to about 90% (TG) (fed or mg/dl, 100, 150, lower reduction, 500 fasting, 180, 200, 300, mg/dl or less, 50-150 mg/dl) 500, 700, 1000, 300, 200, 150, 1200, or 1500, 100 mg/dl or or less than 150, less or a range of 100-2500, 100- 1500, 100-1000, 150-500, 200- 500, 150-300, 150-200, 200- 500 Total 170-300 a range of 130- no worsening no change, 1- Cholesterol 300 mg/dl, 200- 90% reduction (TC) 220, 220-240, (100-200 mg/dl) 240-260, or at least 260, or less than 200 mg/dl TG and HDL-C High TG and TG: at least 150, no worsening low HDL-C 200, 500 mg/dI (ex. TG ≧ HDL-C; less than 150 mg/dl and 40, 50 mg/dl HDL ≦ 40 mg/dl TG/HDL-C at least 3.75 at least 2, 2.5, 3, at least 1% no worsening, at ratio 3.75, 4, 5, 10, or lower least 1% lower, or ranges of 2- 1-90% reduction 3.75, 3.75-10 Non-HDL-C at least 130 at least no worsening no worsening, (mg/dl) 100 mg/dl, 130, or at least 1% 150, 160, 170, lower, or less 190, a range of than 130 mg/dl, 100 to 250 150, 160, 170, 190 Free fatty acid at least 400 less than 400, at at least 1% no change, or at (μEq/I) least 400, 600, lower least 1 to 90% (140-850) 800, 1000 reduction Eicosapentaenoic less than 0.5/ less than 1, at least 5% 5 to about 200% low low 0.75, 0.5, 0.1, increase increase, about Acid/Arachidonic compared to ranges of 0.01-2 2-200-fold Acid (EPA/AA) average level increase (ex. (mol/%)/ or normal (mol/%) subjects Arachidonic High at least 1% no change, 1 to Acid (AA) compared to lower about 90% (ex. mol/%) average level reduction of normal subjects Eicosapentaenoic low compared at least 5% 5 to about 200% Acid (EPA) to average increase increase, about (ex. mol/%) level of 2-500-fold normal increase subjects Docosapentaenoic low compared at least 1% 1 to about 95% Acid (DPA) to average increase increase (ex. mol/%) level of normal subjects Docosahexaenoic low compared Acid (DHA) to average (ex. mol/%) level of normal subjects DPA/AA ratio low compared to average level of normal subjects DPA/AA ratio low compared to average level of normal subjects DHA/DPA ratio low compared to average level of normal subjects Monounsaturated High at least 1% no change, at fatty acid compared to lower least 1% lower (MUFA) average level (ex. mol/%) of normal subjects Palmitoleic High at least 1% no change, at acid (16:1 n7) compared to lower least 1% lower (ex. mol/%) average level of normal subjects Oleic acid High at least 1% no change, a (18:1 n9) compared to lower least 1% lower (ex. mol/%) average level of normal subjects Oleic acid High at least 1% no change, at (18:1 n9)/ compared to lower least 1% lower stearic acid average level (18:0) ratio of normal subjects Palmitoleic High at least 1% no change, at acid (16:1)/ compared to lower least 1% lower Palmitic acid average level (16:0) ratio of normal subjects Stearic acid High no change, or at no change, or at (18:0)/ compared to least 1% lower least 1% lower Palmitic acid average level (16:0) ratio or normal subjects γ-linolenic High no change, or at no change, or at acid(18:3 n6)/ compared to least 1% lower least 1% lower Linolenic acid average level (18:2 n6) ratio subjects AA/Homo-γ- low compared no change, or at no change, or at linolenic acid to average least 1% least 1% (20:3 n6) ratio level of increase increase normal subjects Acrenic acid High no change, or at no change, or at (22:4 n6)/ compared to least 1% lower least 1% lower AA ratio average level of normal subjects Ferritin at least 100, at least 1% at least 1 to (ng/mL) 120, 150, 200, lower about 95% 250, 300, 350, lower 400, or 500 Thioredoxin at least 15, 20, at least 1% at least 1 to (ng/mL) 25, 30, 35, 40, lower about 95% 45, or 50 lower TNFα (Tumor at least 1.5 at least 1, 1.5, at least 1% at least 1 to necrosis 1.6, 1.7, 1.79, lower about 95% factor-α) 1.8, 1.9, 2.0, 2.2, lower (pg/mL) 2.5, 3, 3.5, 4, 5, (1.79 or less) 6, 7 or 10 sTNF-R1 at least 400, at least 1% at least 1 to (Tumor 500, 600, 700, lower about 95% necrosis factor 800, 900, 1000, lower receptor I, 1100, 1200, soluble) 1500, or 2000 (pg/mL) sTNF-R2 at least 500, at least 1% at least 1 to (Tumor 700, 1000, 1200, ower about 95% necrosis factor 1500, 1700, lower receptor 2000, 2200, II, soluble) 2500, 2700, or (pg/mL) 3000 High 0.2 0.1 or more, 0.2, at least 1% at least 5 to Sensitivity C- 0.3, 0.4, 0.5 or lower about 95% reactive more, ranges of lower protien (Hs- 0.1-1, 0.1-0.8, CRP, mg/dl) 0.1-0.5, 0.2-0.5 Connective High at least 1% at least 5 to Tissue Growth compared to lower about 95% Factor (CTGF) average level lower of normal subject Serum Soluble 5 pg/ml or at least 1% at least 5 to CD40 (sCD40, more, 10, 20, lower about 95% pg/ml) 30, 50, 70, 100, lower 120, 150, 170, 200, 220, 250, 300, 350, 400, 450, 500 or more Insulin 1.5 or more 1.6 or less/1.5 no worsening no change, at resistance or more, 1.6, 2, least 1 to about Index (HOMA- 2.5, 3, 3.5, 4 50% lower IR) (1.6 or less) Glycated 5.7 or more a range of 4.3- no worsening no change, at hemoglobin 5.8, 5.7-6.4, 5.8- least 1 to about (HbA1c) 6.5, 6.5-7.0, 7.0- 50% lower (4.3-5.8%) 8.0/5.7 or more, 5.8, 6, 6.5, 7, 7.5, 8, or 8.5 Fasting 100 or more less than 100/ no worsening no change, or at plasma 100 or more, least 1 to about glucose (FRG) 110, 120, 126, 50% lower (mg/dl) 130, 150, 200, (less than 100) 250, 300/ ranges of 100- 110, 100-126 Postprandial 140 or more less than 140, no worsening no change, or at plasma 160, 200/ least 1 to about glucose (after 140 or more, 50% lower a meal) 170, 180, 200, 250, 300, 350 400/ranges of 140-200, 140- 170, 170-200 two-hour 140-200 less than 140, no worsening no change, or at glucose levels 160, 200/140 or least 1 to about on the 75-g more, 170, 180, 50% lower oral glucose 200, 250, 300, tolerance test 350, 400/ (mg/dl) ranges of 140- (OGTT) 200, 140-170, 170-200 Leptin (ng/ml) 5 ng/ml or at least 1% lower at least 1 to more, 10, 12, about 95% 15, 17, 20, reduction 22, 25, 30, 35, 40 or more Serum 5 μg/mL or less, at least 1% no change, at adiponectin 4.5, 4, 3.5, or 3 increase least 1 to about (μg/mL) μg/mL or less 95% increase complement High at least at least 1 to factor D compared to 15% lower about 95% average level reduction of normal subject CK18 High at least 1% lower at least 1 to fragment compared to about 95% average level reduction of normal subject serum High High at least 1% lower at least 1 to mobility group compared to about 95% box 1 protein average level reduction (HMGB1) of normal subject soluble Fas High at least 1% lower at least 1 to antigen compared to about 95% (CD95, sFas) average level reduction of normal subject Hyaluronic 25 ng/mL or at least 1% at least 1 to acid more, 50, 70, lower about 95% (50 ng/mL 100, 120, 150, reduction or less) 200, 250, or 300 or more; 200 mL or less, 100, 70, or 50 or less Type IV 5 ng/mL or at least 1 % at least 1 to collagen more, 6, 7, 8, lower about 95% (7s domain) 10, 12, 15, or 20 reduction (6 ng/mL or more; or less) 25 ng/mL or less, 20, 15, 10, or 6 or less procollagen III 0.2 U/ml or at least 1% at least 1 to peptide more, 0.3, 0.5, lower about 95% 0.3-0.8 U/ml 0.7, 1, 1.2, 1.5, reduction 2, 2.5, 3, 3.5, or 4 or more; 10 or less, 8, 5, 3, 1, or 0.8 or less PAI-1 (ng/mL) 50 or more 50 or less platelet count 150000- 400000/μl or no change no change, at 150000- 300000 less, 300000, least 1% 400000/μl 200000/a range increase of 150000- 300000 BMI 18.5-40 18.5 or more, no change no change, at 20, 25, 30, 35, least 1% 40, or 50 or reduction more; /50 or less, 40, 30, 25, 20 or 18.5 or less; or range of 18.5-25, 25-30, 30-35. 35-40 Direct Bilirubin High compared No worsening No worsening, (0-0.4 mg/dL) to average level 1 to about 90% of normal reduction subject Oleic acid High compared At least 1% lower No change, at (C18:1 n9)/ to average level least 1% lower Palmitic acid of normal (C16:0)ratio subject EPA/AA ratio Low EPA/AA EPA/AA ratio EPA/AA ratio and Hs-CRP ratio and high being 1.0 or less, increases; Hs-CRP Hs-CRP 0.75, 0.6, 0.5, 0.4, decreases 0.25 or less; Hs- CRP being 0.1 mg/dl or higher, 0.2 mg/dl or higher, 0.3 mg/dl or higher Interleukin-1 High compared at least 1% at least 1 to receptor to average level lower about 95% antagonist (IL-1 of normal lower ra) subject sPLA2(Secretory High compared at least 1% at least 1 to phospholipase to average level lower about 95% A2) of normal lower group II A: subject type2A, type II A sPLA2 activity Low compared No worsening to average level of normal subjects Interleukin 2(IL-2) High compared at least 1% at least 1 to to average level lower about 95% of normal lower subject ApolipoproteinA-IV High compared at least 1% at least 1 to to average level lower about 95% of normal lower subject ApolipoproteinC-II High compared at least 1% at least 1 to to average level lower about 95% of normal lower subject CCL2: High compared at least 1% at least 1 to Chemokine(C-C to average level lower about 95% motif) ligand 2 of normal lower subject Thrombospondin 1: High compared at least 1% at least 1 to TSP1 to average level lower about 95% of normal lower subject IL-3 receptor High compared at least 1% at least 1 to (interleukin-3 to average level lower about 95% receptor) alpha of normal lower chain subject Lymphocyte High compared at least 1% at least 1 to antigen 6 to average level lower about 95% comlex, locus D of normal lower subject MMP12: High compared at least 1% at least 1 to Matrix to average level lower about 95% metallopeptidase of normal lower 12 subject MMP13: High compared at least 1% at least 1 to Matrix to average level lower about 95% metallopeptidase of normal lower 13 subject Trehalase High compared at least 1% at least 1 to (brush-border to average level lower about 95% membrane of normal lower glycoprotein) subject TIMP1: High compared at least 1% at least 1 to Tissue inhibitor to average level lower about 95% of of normal lower metalloproteinase 1 subject COL1a1: High compared at least 1% at least 1 to Procollagen type I, to average level lower about 95% alpha 1 of normal lower subject Complement High compared at least 1% at least 1 to factor D to average level lower about 95% (adipsin) of normal lower subject TNFR (tumor High compared at least 1% at least 1 to necrosis factor to average level lower about 95% receptor) of normal lower superfamily, subject member 19 (TAJ) TNFAIP (tumor High compared at least 1% at least 1 to necrosis factor to average level lower about 95% alpha induced of normal lower protein) 6 subject VLDLR (Very High compared at least 1% at least 1 to low density to average level lower about 95% lipoprotein of normal lower receptor) subject Lipoprotein High compared at least 1% at least 1 to lipase to average level lower about 95% of normal lower subject Ear (Eosinophil High compared at least 1% at least 1 to associated to average level lower about 95% ribonuclease) A of normal lower family, subject members 1, 2, 3, and 12 INSL5: Insulin Low compared At least 1% like 5 to average level increase of normal subjects TGF β 2: Low compared At least 1% Transforming to average level increase growth factor of normal beta 2 subjects HAMP: Low compared At least 1% Hepcidin to average level increase antimicrobial of normal peptide 1 subjects Lipase member Low compared At least 1% H: to average level increase LIPH of normal subjects CYP7B1: Low compared At least 1% Cytochrome to average level increase P450 family 7 of normal subfamily b subjects polypeptide 1

TABLE 2 Pre-treatment baseline After dosing (effect) values Item Typical Observable Observable Normal Typical Ranges or Typical Ranges or Values, Units) Range(s) Values Range(s) Values 1 1-HETE High compared at least 1% at least 1 to (11-hydroxy- to average level lower about 95% 5,8,12,14- of normal lower eicosatetraenoic subject acid) Total HEPEs Low compared At least 1% (hydroxy- to average level increase eicosapentaenoic of normal acids)/total HETEs subjects (Hydroxy- eicosatetraenoic Acids) ratio Glycocholate High compared Twice or more at least 1% lower to average level than twice as high of normal as normal subject subject Taurocholate High compared Twice or more at least 1% lower to average level than twice as high of normal as normal subject subject Glycocholate/ High compared Twice or more at least 1% lower Glycine ratio to average level than twice as high of normal as normal subject subject Taurocholate/ High compared Twice or more at least 1% lower Taurine ratio to average level than twice as high of normal as normal subject subject Total fatty acids Low compared At least 1% of 20 to 24 to average level increase carbon atoms of normal (C20-24)/total subjects fatty acids of 16 carbon atoms (C16) ratio (ex. μg/ml/μg/ml, wt %/wt %) Total omega-3 Low compared At least 1% polyunsaturated to average level increase fatty acids of of normal 20 to 24 carbon subjects atoms(C20-24)/ total fatty acids of 16 carbon atoms (C16) ratio (ex. μg/ml/μg/ml, wt %/wt %) Total fatty acids Low compared At least 1% of 20 to 24 to average level increase carbon of normal atoms(C20-24)/ subjects total fatty adds of 18 carbon atoms (C18) ratio (ex. μg/ml/μg/ml, wt %/wt %) Total omega-3 Low compared At least 1% polyunsaturated to average level increase fatty acids of of normal 20 to 24 carbon subjects atoms(C20-24)/ total weight of fatty acids of 18 carbon atoms (C18) ratio (ex. μg/ml/μg/ml, wt %/wt %) IL-10 No change At least 1% (Interleukin-10) or Low increase compared to average level of normal subjects Small dense LDL No change at least 20 mg/dl, at least 1% lower or High 25, 30, 40, 50, at compared to least 60 mg/dl average level of normal subjects RLP-TG No change at least 10 mg/dl, at least 1% lower (Remnant-like or High 20, 30, 40, 50, 70, lipoprotein compared to 80, 100, 120, at particles- average level of least 150 mg/dl triglyceride) normal subjects RLP-C No change At least 4.5 mg/dl, at least 1% lower, (Remnant-like or High 5, 5.2, 5.5, 6, 8, or no change lipoprotein compared to 10, 12, at least 15 particles- average level of mg/dl cholesterol) normal subjects Whole Blood High compared to at least 1% lower at least 1% lower viscosity average level of (cP/mPa • s) normal subject Plasma viscosity High compared to No worsening (cP/mPa • s) average level of normal subject IL-10 Low compared At least 1% (Interleukin-10)/ to average level increase TNFα ratio of normal subject IL-10 Low compared At least 1% (Interleukin-10)/ to average level increase sCD40 ratio of normal subject Serum Low compared At least 1% adiponectin/ to average level increase TNFα ratio of normal subject Serum Low compared At least 1% adiponectin/ to average level increase sCD40 ratio of normal subject

TABLE 3 11-HETE Prostaglandins Other Lipid Mediat. 2011 April; 94(3-4): 81-7. HETE, HEPE Analysis of omega-3 and omega-6 fatty acid-derived lipid metabolite formation in human and mouse blood samples. Glycocholate Metabolism. 2011 March; 60(3): 404-13. Taurocholate Plasma metabolomic profile in nonalcoholic fatty liver disease. IL-10 Obes Surg. 2010 July; 20(7): 906-12. Pro- and anti-inflammatory cytokines in steatosis and steatohepatitis. Small dense LDL Diabetol Metab Syndr. 2012 July 18; 4(1): 34. Fatty liver in men is associated with high serum levels of small, dense low-density lipoprotein cholesterol. RLP-TG Clinica Chimica Acta 413 (2012) 1077-1086 RLP-C The characteristics of remnant lipoproteins in the fasting and postprandial plasma. Connective Tissue Growth Regul Pept. 2012 September 4; 179(1-3): 10-14. Factor (CTGF) Connective tissue growth factor level is increased in patients with liver cirrhosis but is not associated with complications or extent of liver injury. Serum Soluble CD40 (sCD40) Apoptosis 2004; 9: 205-210 Role of circulating soluble CD40 as an apoptotic marker in liver disease. Complement factor D Int Immunopharmacol. 2009 November; 9(12): 1460-3. Serum adipsin levels in patients with seasonal allergic rhinitis: preliminary data. CK18 fragment Aliment Pharmacol Ther. 2010 December; 32(11-12): 1315-22. A new composite model including metabolic syndrome, alanine aminotransferase and cytokeratin-18 for the diagnosis of non- alcoholic steatohepatitis in morbidly obese patients. Serum High mobility group PLoS One. 2012; 7(4): e34318. box 1 protein (HMGB1) Diagnostic significance of serum HMGB1 in colorectal carcinomas. fatty acid amount and fatty Clinical Nutrition (2002) 21 (3) 219-223 acid composition ratio in Plasma total and free fatty acids composition in human non- blood alcoholic steatohepatitis. Ferritin, Thioredoxin J Hepatol. 2003 January; 38(1): 32-8. Serum thioredoxin levels as a predictor of steatohepatitis in patients with nonalcoholic fatty liver disease. sTNF-R1, sTNF-R2 Diabetes Care. 2010 October; 33(10): 2244-9. Epub 2010 July 27. Association between systemic inflammation and incident diabetes in HIV-infected patients after initiation of antiretroviral therapy. Hs-CRP J Hepatol. 2011 September; 55(3): 660-5. C-reactive protein levels in relation to various features of non- alcoholic fatty liver disease among obese patients. soluble Fas antigen (CD95, J Transl Med. 2009 July 29; 7: 67. sFas) Short term effects of milrinone on biomarkers of necrosis, apoptosis, and inflammation in patients with severe heart failure. Whole Blood viscosity British Journal of Haematology, 1997 96, 168-173 Plasma viscosity Blood viscosity and risk of cardiovascular events: the Edinburgh Artery Study Items in Table1(1-8, 1-9, 1-10) WO2011/046204

Example—Treatment of NASH

To evidence the usefulness of the present invention for the treatment of NASH, patients are evaluated for inclusion in the treatment regimen, treated for NASH, and evaluated for effectiveness of the treatment as follows:

Patients are histologically diagnosed with NASH within six months of the initiation of treatment and are willing to submit to a further liver biopsy at the end of the treatment regimen to evaluate effectiveness of the treatment.

1. Inclusion Criteria:

Patients are definitively diagnosed with NASH (via liver biopsy) and exhibit a NAS score of greater than or equal to 4 by a pathologist.

Patients can be of either gender but are greater than 18 years of age.

Patients with diabetes, impaired glucose tolerance or metabolic syndrome that have been on stable dosage of anti-diabetic agents for at least six months prior to the liver biopsy are suitable for treatment.

2. Exclusion Criteria:

Patients may be excluded for treatment based upon an inability or unwillingness to have a liver biopsy for confirming the diagnosis of NASH, having a diagnosis of cirrhosis by pathologist, exhibiting previous bariatric surgery or biliary diversion (i.e. gastric bypass), esophageal banding or gastric banding; serum ALT values of greater than 330 UL, drug use associated with steatohepatitis within 6 months prior to initiation of treatment, such as with corticosteroids, high dose estrogens, methodtrexate, amiodarone, anti-HIV drugs, tamoxifen, or diltiazem; alcohol consumption of greater than 30 g/day, concurrently or for more than three consecutive months within five years prior treatment; a blood alcohol level greater than 0.02% at the time of baseline evaluation; evidence of active substance abuse; including prescription or recreational drugs, the presence of other liver diseases such as acute or chronic hepatitis C, acute or chronic active hepatitis B, Wilson's, autoimmune, alpha-1-antitrypsin and hemochromatosis or HIV infection; renal insufficiency; symptomatic coronary; peripheral or neurovascular disease; symptomatic heart failure or advanced respiratory disease requiring oxygen therapy; a history of cerebral or retinal hemorrhage or other bleeding diathesis.

3. Key Criteria for Measuring Baseline and Post Treatment Values:

Patients to be treated are evaluated for one or more of the following criteria.

a) Primary Long-Term Efficacy Outcome Measure

Histology at treatment month 12.5 to evaluate the NAS score, as a comparison to the baseline score measured pre-treatment. (NAS)

b) Primary Short-Term Efficacy Outcome Measure

Change from baseline in ALT levels at Month 3 and Month 6 of treatment.

c) Secondary Efficacy Outcome Measures

Overall NAS score

Feature scores including fibrosis, ballooning degeneration, inflammation and steatosis

Liver function tests (AST, alkaline phosphataise, bilirubin, GGT, Albumin)

Cholesterol (including HDL and LDL)

Triglycerides

Fatty acid assay

Ferritin

Thioredoxin

Pro-inflammatory cytokines (TNF-alpha, sTNF-R1, sTNF-R2, Hs-CRP, CTGF, sCD40)

Insulin sensitivity (HOMA-IR)

HbA1c

Glucose

Leptin, Serum adiponectin and complement factor D

CK18 fragment and Serum HMGB1

soluble Fas antigen

Hyaluronic acid

Type IV collagen (7S domain)

Procollagen III peptide

d) Safety Outcome Measures

Adverse Events

Hematology/biochemistry/urinalysis

ECG (including QT/QTc measurement)

e) Pharmacokinetic Outcome Measures

EPA, DPA and DHA

Day 1

On Day 1, samples for plasma concentration are obtained at predose and 0.5, 1, 2, 4, 5 and 6 hours after Dose #1 and Dose #3; after Dose #2, samples are obtained at 2, 4, 5 and 6 hours post-dose. After Dose #3, samples are also obtained at 8 and 12 hours post-dose (20 and 24 hours after Dose #1 [prior to the morning dose on Day 2]) C_(max) (Dose #1 and Dose #2s) and C_(max), T_(max), T_(1/2), AUG_(0-t) after third Dose are derived from plasma concentrations

Days 29, 85, 169 and 365 (Visits 3, 5, 7 and 9)

-   A single sample is obtained prior to the morning dose (trough) on     Visits 3, 5, 7 and 9. -   Css is determined from plasma concentrations

4. Concomitant and Medications:

Particular medications can be prohibited or permitted during treatment according to the invention for NASH.

The following medications can be prohibited during treatment:

Omega-3-acid ethyl esters and omega-3-PUFA containing supplements >200 mg per day

Vitamin E >60 IU per day

Thiazolidinediones (e.g. pioglitazone, rosiglitazone)

The following medications may be used during the treatment according to the specified restrictions:

Subjects may continue prescription or over-the-counter medications or herbal remedies such as HMG-CoA reductase inhibitors (stains), fibrates, probucol, ezetimibe, ursodiol (UDCA), taurine, betaine, N-acetylcysteine, s-adenosylmethionine (SAM-e), milk thistle, anti-TNF therapies, or probiotics

Subjects may continue the following anti-diabetic medications: biguanides (metformin), insulin, sulfonylureas, alpha-glucosidase inhibitors (acarbose), dipeptidyl-peptidase 4 inhibitors (sitagliptin, saxagliptin), and phenylalanine derivatives (nateglinide, repaglinide)

Subjects may continue receiving anti-platelet therapy and anti-thrombotic agents (e.g. warfarin, Aspirin(ASA), and clopidogrel) after study commencement should be monitored closely during the study for bleeding problems.

5. Treatment

Patients are treated with EPA-E comprised of two daily treatments, but the total daily dose of EPA-E being 1800 mg or 2700 mg per day, divided into dosage amounts of 600 mg TID or 900 mg TID, respectively.

Treatment with EPA-E is continued for 12 months.

Patients are periodically evaluated for the selected criteria, such as at month 1, month 3, month 6 and month 12 of treatment.

After 12 months of treatment, patients are evaluated for the criteria noted above, including liver biopsy, NAS score, steatosis, lobular inflammation, ballooning and fibrosis stage, and one or more of the other criteria listed above in Tables 1 and 2.

The invention being thus described, it will be apparent to one of ordinary skill in the art that various modifications of the materials and methods for practicing the invention can be made. Such modifications are to be considered within the scope of the invention as defined by the following claims.

Each of the references from the patent and periodical literature cited herein is hereby expressly incorporated in its entirety by such citation. 

The invention claimed is:
 1. A method for treating or alleviating non-alcoholic steatohepatitis (NASH), comprising administering eicosapentaenoic acid, ethyl eicosapentanoate, or a combination thereof at a dosage of 0.6 g or 0.9 g three times per day to a human subject, wherein the administering results in one or more of: an increase of at least 1% to about 95% of serum adiponectin concentration, an increase of 1% to about 90% of albumin concentration, a reduction of at least 1% to about 50% of glycated hemoglobin (HbA1c) concentration, a reduction of 1% to about 90% of alkaline phosphatase (ALP) concentration, a reduction of at least 1% to about 95% of Type IV collagen 7S concentration, or a reduction of at least 1% to about 95% of hyaluronic acid concentration; and wherein the administering results in: at least 1% increase of interleukin-10 (IL-10) concentration, at least 1% lower of small dense LDL concentration, or a concentration reduction of at least 1% to about 95% of: interleukin-2 (IL-2); interleukin-3 receptor alpha chain; apolipoproteinA-IV; apolipoproteinC-II; chemokine (C-C motif) ligand 2 (CCL2); thrombospondin 1 (TSP1); lymphocyte antigen 6 complex locus D; matrix metallopeptidase 12 (MMP12); matrix metallopeptidase 13 (MMP13); trehalase; tissue inhibitor of metalloproteinase 1 (TIMP1); procollagen type I alpha 1 (COL1a1); tumor necrosis factor receptor (TNFR) superfamily member 19; tumor necrosis factor alpha induced protein (TNFAIP) 6; very low density lipoprotein receptor (VLDLR); lipoprotein lipase; eosinophil associated ribonuclease (EAR) A1, EAR-A2, EAR-A3, EAR-A12; or any combination thereof; in the subject.
 2. The method of claim 1, wherein the subject is not diabetic.
 3. The method of claim 1, wherein the subject is not taking any anti-diabetic drug.
 4. The method of claim 1, comprising administering the ethyl eicosapentanoate to the subject.
 5. The method of claim 1, wherein the administering is continued for 3, 6, 9, or 12 months.
 6. The method of claim 1, wherein the eicosapentaenoic acid, ethyl eicosapentanoate, or a combination thereof is dosed at 0.6 g three times per day.
 7. The method of claim 1, wherein the eicosapentaenoic acid, ethyl eicosapentanoate, or a combination thereof is dosed at 0.9 g three times per day.
 8. The method of claim 1, wherein the eicosapentaenoic acid, ethyl eicosapentanoate, or a combination thereof is in a form of a self-emulsifying composition.
 9. The method of claim 1, wherein the administering results in at least 1% increase of interleukin-10 (IL-10) concentration in the subject.
 10. The method of claim 1, wherein the administering results in at least 1% lower of small dense LDL concentration in the subject.
 11. The method of claim 1, wherein the administering results in a concentration reduction of at least 1% to about 95% of interleukin-2 (IL-2) in the subject.
 12. The method of claim 1, wherein the administering results in a concentration reduction of at least 1% to about 95% of interleukin-3 receptor alpha chain in the subject.
 13. The method of claim 1, wherein the administering results in a concentration reduction of at least 1% to about 95% of apolipoproteinA-IV, apolipoproteinC-II, or a combination thereof, in the subject.
 14. The method of claim 1, wherein the administering results in a concentration reduction of at least 1% to about 95% of chemokine (C-C motif) ligand 2 (CCL2) in the subject.
 15. The method of claim 1, wherein the administering results in a concentration reduction of at least 1% to about 95% of thrombospondin 1 (TSP1) in the subject.
 16. The method of claim 1, wherein the administering results in a concentration reduction of at least 1% to about 95% of lymphocyte antigen 6 complex locus D in the subject.
 17. The method of claim 1, wherein the administering results in a concentration reduction of at least 1% to about 95% of matrix metallopeptidase 12 (MMP12), matrix metallopeptidase 13 (MMP13), or a combination thereof, in the subject.
 18. The method of claim 1, wherein the administering results in a concentration reduction of at least 1% to about 95% of trehalase in the subject.
 19. The method of claim 1, wherein the administering results in a concentration reduction of at least 1% to about 95% of tissue inhibitor of metalloproteinase 1 (TIMP1) in the subject.
 20. The method of claim 1, wherein the administering results in a concentration reduction of at least 1% to about 95% of procollagen type I alpha 1 (COL1a1) in the subject.
 21. The method of claim 1, wherein the administering results in a concentration reduction of at least 1% to about 95% of tumor necrosis factor receptor (TNFR) superfamily member 19 in the subject.
 22. The method of claim 1, wherein the administering results in a concentration reduction of at least 1% to about 95% of tumor necrosis factor alpha induced protein (TNFAIP) 6 in the subject.
 23. The method of claim 1, wherein the administering results in a concentration reduction of at least 1% to about 95% of very low density lipoprotein receptor (VLDLR) in the subject.
 24. The method of claim 1, wherein the administering results in a concentration reduction of at least 1% to about 95% of lipoprotein lipase in the subject.
 25. The method of claim 1, wherein the administering results in a concentration reduction of at least 1% to about 95% of eosinophil associated ribonuclease (EAR) A1, EAR-A2, EAR-A3, EAR-A12, or any combination thereof, in the subject.
 26. The method of claim 1, wherein the subject is a possible or definite NASH subject. 